15.1 Introduction
Obstruction of the ejaculatory ducts can negatively impair semen quantity and quality to the extent of azoospermia, compromising fertility. Further, it may lead to symptoms including ejaculatory disorders (e.g., painful ejaculation, nonprojectile ejaculation, diminished sense of orgasm, or hematospermia), dysuria, and variable extents of pelvic and genital pain [1,2]. Anatomically, the left and right ejaculatory ducts enter the prostatic urethra at the level of the utricle of the prostate. Bilateral complete obstruction of ejaculatory ducts typically leads to low-volume azoospermia with acidic pH in semen that is negative for fructose. Some patients who have acquired this condition may present with painful ejaculation or general pelvic pain. Unilateral or incomplete ejaculatory duct obstruction (EDO), on the other hand, may lead to variable deterioration of semen parameters. In the context of male infertility, ejaculatory duct obstruction may be managed surgically by transurethral resection of the ejaculatory duct (TURED) to remove the obstructed segment of the excurrent ductal system within the prostate. The approach to TURED will be the focus of this chapter. Other surgeries of the seminal vesicles for other pathologies such as cyst or neoplasia will not be discussed in this chapter.
Normally, the ejaculatory ducts contain a valve-like mechanism that prevents reflux of urine into the excurrent ductal system. Though TURED can relieve the obstruction, reflux of urine up the excurrent ductal system may develop in a significant portion of men after successful TURED [3], causing chemical and/or bacterial epididymitis. Not infrequently, additional significant complications (see Section 15.7, “Complications”) may develop postoperatively. Thus, TURED should not be considered a benign procedure and should only be done by experienced surgeons after careful evaluation and counseling with patients. Alternative options for management of symptoms of ejaculatory obstruction (e.g., for pelvic pain or pain with ejaculation) and infertility (e.g., with sperm retrieval in conjunction with assisted reproduction) must be discussed prior to undertaking TURED.
15.2 Preoperative Evaluations
A detailed history should focus on any history of infertility, symptoms of pelvic/genital pain, sexual, ejaculatory, and voiding dysfunction. Drugs that are known to impair ejaculation, such as α-adrenergic antagonists, selective serotonin reuptake inhibitors, thiazides, or certain antipsychotic and antihypertensive agents, should be discontinued. A thorough physical examination focusing on the prostate and genital examination (such as scrotal and spermatic cord anomalies, testicular size and texture, epididymal fullness and anomalies, presence of vas deferens, prostate volume, and anomalies) must be carefully documented. Postejaculation urinalysis should confirm the absence of retrograde ejaculation. Urine culture and urinalysis should be performed prior to surgery to confirm the absence of urinary tract infection. Hormonal profile including morning serum total or bioavailable testosterone, estradiol, luteinizing hormone, and follicle-stimulating hormone should be performed.
In men with ejaculatory duct obstruction, semen analyses, performed according to the standards of the WHO [4], generally reveal low-volume azoospermia with acidic pH. However, patients with incomplete obstruction (e.g., unilateral or partial) may have variable semen parameters. Surgical correction of ejaculatory duct obstruction is not contraindicated in non-azoospermic symptomatic men (e.g., those with pelvic or ejaculatory pain, low volume of semen or infertility) or men with coexisting spermatogenic dysfunction (as indicated by elevated serum FSH level, hypogonadism, hypotrophic testis). However, patients with this presentation should be clearly informed that even after successful surgical correction of ejaculatory duct obstruction, there may not be any or adequate amount of sperm returning to the ejaculate for fertility purpose.
Transrectal ultrasound (TRUS) to evaluate the prostate to document any intraprostatic cysts, dilatation (e.g., seminal vesicle transverse diameter > 1.5 cm, vasal ampulla transverse diameter > 6 mm, ejaculatory diameter > 2 mm) [5] or anomalies (e.g., cysts, stones, or calcifications) of the ejaculatory ducts or seminal vesicles can provide additional information important for the planning of TURED. Generally, a single large midline prostatic cyst (Mullerian duct cyst) viewed on TRUS may represent an obliterated cavity where the outflow of the ejaculatory duct empties (Figure 15.1). Resection to unroof such a cavity may unobstruct the ejaculatory ducts. In the absence of such a cavity, transurethral resection will be a challenge as the surgeon must carefully make consecutive shallow resections until confirmation of patency of the ejaculatory ducts. It should be noted that occasionally intraprostatic cysts, particularly when they are multiple, small in size, or off the midline, do not necessarily represent a cavity obstructing the outflow of the ejaculatory ducts. In this setting, the surgeon must also carefully make shallow resection until patency of the ejaculatory ducts is confirmed.
Figure 15.1 Sagital view of TRUS revealing a midline cystic cavity within the center of the prostate.
Genetic evaluation for mutations of the cystic fibrosis transmembrane regulator (CFTR) should be performed in men with congenital anomalies of the male excurrent ductal system such as the unilateral or bilateral absence of the vasa deferentia, obstruction, and partial agenesis of the epididymides. In these men the cause of infertility is often solely due to obstruction at the levels of vasa deferentia and epididymides. CFTR gene mutation evaluation may also be considered in men with congenital ejaculatory duct obstruction in spite of the vasa deferentia being palpable. Even for men with palpable vasa and intact epididymides presenting with isolated anomalies of the seminal vesicles (IASV) or bilateral EDO, mutations of the CFTR genes have been reported in 13% of IASV and as high as 86% of bilateral EDO patients [6]. As these men will have a reasonably good chance for procreation, particularly with assisted reproduction, appropriate genetic counseling for men with documented CFTR mutations should be offered. Additional workup, such as pelvic imaging with computed tomography (CT) or magnetic resonance imaging (MRI) [7], testicular biopsy, and cystoscopy may be performed as indicated based on the clinical presentation and findings of the patients. Seminal vesicle aspiration [8], for examination of sperm, can be an alternative to testicular biopsy to confirm spermatogenic activities. Less commonly performed investigations such as seminal vesicle manometry [9], vesiculoscopy, vesiculography, chromotubation [10,11], and scintigraphy [12] have been described as alternative means to confirm the diagnosis of ejaculatory duct obstruction.
15.3 Preoperative Counseling
When obtaining informed consent, patients should be counseled on the potential complications of TURED, which include, in addition to anesthesia-related complications and general surgical complications (such as wound infection, vascular injury, and pain) – from highest to the lowest rates of occurrence – urine reflux to the excurrent ductal system, vasal obstruction, persistent ejaculatory duct obstruction, retrograde ejaculation, ejaculation of urine, incontinence, rectal injury, and urethral stricture. Thus, TURED should not be considered a benign procedure and should only be done by experienced surgeon after careful evaluation and counseling with patients. Alternative options for management of symptoms of ejaculatory obstruction (e.g., for pelvic pain or pain with ejaculation) and infertility (e.g., with sperm retrieval in conjunction with assisted reproduction) must be discussed prior to undertaking TURED.
Men with unilateral or incomplete bilateral ejaculatory duct obstruction may present with nonazoospermic infertility (i.e., semen parameters ranging from a combination of oligo-astheno-teratospermia to normal semen parameters) or ejaculatory or pelvic/genital pain symptoms. Unfortunately, these men will usually not be investigated specifically for incomplete ejaculatory duct obstruction. Instead, their presentations are often considered idiopathic and managed with assisted reproduction for infertility and analgesic/antibiotics for pain, both with variable success. With the increase in the access of various imaging modalities including TRUS and MRI, some of these men, particularly those who are refractory to other forms of therapies for their symptoms, may be correctly diagnosed to have incomplete ejaculatory duct obstruction that require surgical management. However, it is important to emphasize that these men must be properly counseled on the potential risks and benefits prior to undergoing TURED. Alternative options for symptomatic management and fertility management such as with assisted reproduction must be discussed and, as mentioned earlier, sperm cryopreservation prior to surgery and intraoperatively must be offered. Though invasive and uncommonly performed, seminal vesicle manometry [9] may be considered to establish the presence of a significant obstruction prior to considering surgical management.
15.4 Surgical Approach to TURED
15.4.1 Vasography
When performing TURED, particularly when there is a sizable single prostatic midline cyst, many fertility specialists proceed with TURED without performing a vasography in the same setting. As vasography carries risks of vasal obstruction (see Section 15.7.2), this consideration is especially important when TURED is performed by surgeons who do not routinely perform vasal surgeries that require microscopic surgical skills and special equipment. However, a concomitant vasography provides the following benefits in managing men with EDO: (1) it allows for evaluation if there is epididymal obstruction that would suggest not to proceed with TURED (see later); (2) it allows for retrieval of sperm for cryopreservation for assisted reproduction should reconstruction fail; (3) it allows for intraoperative confirmation of patency of the excurrent ductal system after TURED is performed (see Section 15.4.5).Generally, vasography should be performed in the same setting with surgical correction of ejaculatory duct obstruction [13]. The surgical procedure described in the following begins with a high scrotal incision for vasography. It should be noted that alternative approaches such as percutaneous delivery of the vas deferens for vasography (e.g., using techniques similar to no-scalpal vasectomy), transrectal vasography, or seminal vesiculography [14] may also be used. In the latter two approaches, the same bowel prep and antibiotic coverage used for transrectal prostate biopsy should be employed.
15.4.3 Perioperative Antibiotics
Urinary tract infection should be treated before surgery. While most experts agree that perioperative prophylactic antibiotics should be used for transurethral resection of prostate (TURP), there is a lack of literature evaluating their values for TURED, which is generally less extensive a surgery compared to TURP.
15.4.4 Position
The patient should be in supine position for the vasography and then placed in lithotomy position for the transurethral part of the surgery.
15.4.5 Procedure
After prepping and draping the scrotal, inguinal, and perineal area with antiseptic solution while the patient is in a supine position, bilateral high scrotal incision is made to expose the vas deferens at the junction of the straight and convoluted portions. Under an operating microscope at 10-power magnification, the vasal sheath is longitudinally incised to minimize damage to the vasal vessels. A clean segment of bare vas is delivered and, under 25-power magnification, a 15º microknife is used to transversely hemitransect the vas until the lumen is revealed (Figure 15.2). Any fluid exuding from the lumen is examined microscopically for sperm. Cryopreservation of the vasal fluid for sperm prior to TURED should be considered, particularly if motile sperm are found. This can be achieved with repeated aspiration of the vasal fluid with a 24 G angiocatheter attached to a 1 ml tuberculin syringe.
Figure 15.2 A clean segment of bare vas is delivered and, transversely hemitransected with a #11 blade to reveal the vas lumen. Any fluid exuding from the lumen is examined microscopically for sperm.
If the vasal fluid is devoid of sperm despite repeated sampling after milking the epididymis and convoluted vas, epididymal obstruction is likely present (in the absence of any clinical suspicion of ipsilateral testicular dysfunction). In the presence of epididymal obstruction, if the ipsilateral distal vas deferens or ejaculatory duct are obstructed, it is best to abandon attempts at reconstruction and simply perform microsurgical epididymal sperm aspiration or testicular sperm retrieval and cryopreservation for future IVF/ ICSI. This is because the overall success of simultaneous vasoepididymostomy and TURED, two technically challenging procedures, are generally low [15].
To evaluate if the distal vas deferens and ejaculatory duct are patent, the lumen of the vas toward the ejaculatory duct is then cannulated with a 24-G angiocatheter sheath and injected with 1 mL of lactated Ringer solution with 1 mL tuberculin syringe to confirm its patency (Figure 15.3). If the Ringer solution passes easily, formal vasography and ejaculatory duct resection are not necessary. If further proof of obstruction of the excurrent ductal system is desired, 1 mL of 1:20 diluted indigo carmine or methylene blue may be injected intravasally toward the ejaculatory duct and the bladder catheterized. The absence of blue/green dye in the urine confirms obstruction of the ipsilateral vas and ejaculatory duct.
Figure 15.3 The vas is cannulated with a 24-gauge angiocatheter with fluid injected towards the abdominal end.
Once obstruction is confirmed toward the ejaculatory duct, a 2-0 Proline suture can be passed intravasally toward the ejaculatory duct and a clamp placed on the suture when it passes no farther. This is particularly useful in patients who had undergone ipsilateral inguinal surgery, such as a hernia repair, to allow confirmation that the vasal obstruction is not at the inguinal area but farther at the ejaculatory duct. Formal vasography may be performed by passing a 3 French whistle-tip ureteral catheter toward the seminal vesicle end of the vas. A 16 French Foley catheter is placed in the bladder, and the balloon is filled with 5 mL of air. Placing the balloon on gentle traction before vasography prevents reflux of contrast into the bladder, which can obscure detail. The air-filled balloon also identifies the location of the bladder neck relative to any obstruction. Vasogram is performed with the injection of 0.5 mL of water-soluble contrast media. Only if the vasogram confirms obstruction is at the level of the ejaculatory duct, instead of at the vas deferens, should one proceed to perform a transurethral resection of the ejaculatory duct. The ureteral catheter should be left in place inside the vas for later during the transurethral resection of the ejaculatory duct.
A similar procedure should be performed on the contralateral side. The dilution for indigo carmine or methylene blue for the second side should be more concentrated at 1:5 to allow visual distinction of the two sides during intravasal injection. The patient is then carefully placed in lithotomy position and prepped and draped for transurethral procedure.
The setup is identical to TURP. Although the use of holmium laser for TURED has been described [16,17], fertility specialists who do not perform prostate resection with laser routinely may choose to use conventional TURP setup as described here. Cold knife incision alone almost always leads to reobstruction and is not a treatment of choice for TURED. It is advisable to use an O’Connor-type drape in which a rectal hole is provided to allow prostate digital palpation during the resection. Keep in mind that patients undergoing TURED are generally younger with thinner prostates than men undergoing TURP for benign prostate hyperplasia/lower urinary tract symptoms (BPH/LUTS). The tactile sensation when palpating the prostate during TURED can help to minimize the risk of too deep a resection that can potentially lead to rectal damage. The resectoscope, with the 24 French cutting loop, is engaged with a finger placed in the rectum providing anterior displacement of the posterior lobe of the prostate (Figure 15.4). The ejaculatory ducts course between the bladder neck and the verumontanum and exit at the level of and along the lateral aspect of the verumontanum. Resection of the verumontanum will often reveal the dilated ejaculatory duct orifice or cyst cavity where blue dye injected through the vasa comes out (Figure 15.5). Resection should be carried out in this region with great care in order to preserve the bladder neck proximally, the striated sphincter distally, and the rectal mucosa posteriorly. In case of unilateral TURED, a Collins knife may be used and aim at an angle to resect only one side of the verumontanum (Figures 15.6 and 15.7). Efflux of indigo carmine from dilated orifices confirms adequate resection. Avoid excessive coagulation that can lead to scarring and reobstruction of the ejaculatory ducts (Figure 15.8).
